Is Saturation Biopsy Still a Viable Alternative to Fusion Biopsy in the Era of Multiparametric MRI? A Comparative Analysis in Patients With Prior Negative Biopsy

BACKGROUND: We aimed to compare the diagnostic accuracy of transrectal ultrasound (TRUS)-guided saturation biopsy (SB) and multiparametric MRI (mpMRI)-TRUS fusion-guided combined biopsy (CB) in patients with prior negative prostate biopsies. METHODS: We retrospectively analyzed data from 160 patients who underwent transrectal prostate biopsy between January 2014 and March 2021. All had at least one prior negative biopsy. 80 patients underwent SB with a 20-core TRUS-guided approach. The remaining 80 patients, with mpMRI-detected PIRADS ≥ 3 lesions, underwent CB including 12-core systematic plus 2-4 targeted cores per lesion. Prostate cancer and clinically significant prostate cancer (csPCa) detection rates, and clinical parameters were compared between groups. RESULTS: The groups had no statistically significant differences in baseline characteristics. The PCa detection rate was 20% in the CB group and 16.3% in the SB group (p = 0.682). csPCa detection rates were also similar: 11.3% in the CB cohort and 7.5% in the SB cohort (p = 0.589). Notably, the CB subgroup with PI-RADS ≥ 4 lesions had a significantly higher csPCa detection rate (28.6%) than SB group (7.5%) (p = 0.016). Patients diagnosed with PCa had significantly lower free PSA and free/total PSA ratios (p < 0.05). Complication rates were low and similar in both groups. CONCLUSIONS: CB demonstrates the highest diagnostic yield for detecting csPCa, particularly in patients with PI-RADS ≥ 4 lesions. However, in resource-limited settings lacking mpMRI, systematic saturation biopsy remains a viable, safe, and effective alternative. PSA derivatives may serve as complementary tools to refine biopsy decisions.